Introduction to Module #3

Welcome back! I hope that everyone is doing well. Let’s get started with the 3rd module. Using the GET WISE framework, the following items will be covered in the 3rd module:

During this module, we will: (project GET WISE)

(G): Goals will be set related to complex transfer skills.
(E): The exercise program will be discussed and reviewed in the online discussion session
(T): Training will be provided on the performance of complex transfer skills (toilet, vehicle, and bed).

W – Wheelchair/Scooter skills in challenging environments will be discussed.
I – Fall management plans will be discussed which will help increase your confidence in your ability to recovery from a fall if one does occur.
S
E – We will discuss the use of assistive technology being part of your environment and how it can have a positive influence on fall prevention.

I hope that you enjoy the material for this week.

How to Fall and Fall Recovery Introduction/How to fall

In this segment we are going to be discussing the concept of how to fall to minimize injuries and what to do after a fall occurs. While the main focus of this program is to attempt to prevent a fall from occurring, it is important to be able to appropriately manage a fall if one does occur. Having confidence that you can recover from a fall and knowing what to do may help to make you feel less fearful about falling and have increased confidence to perform your desired activities in the community.

Project on screen: Please now turn to page 71 of your manual.

We will now start looking into the idea of how to fall. Learning “how” to fall is a very important part of managing the secondary problems associated with falls. While the goal of this program is to prevent falls from happening, some falls will still occur. Learning how to manage a fall when it does occur is important to minimize injury.

We will now be watching a video showing how to fall safely. This video is also available on the study website for you to watch at a later date if you would like. The bullet points in your manual correspond to the key information presented in the video.

Insert how to fall video

Here are a few other important tips for both manual and power wheelchair users:

Manual wheelchair users: If you start to fall backwards and cannot stop the movement, tuck your head and grab the wheels. This will force the chair’s push handles or backrest to take the brunt of the fall and protect your head. A rigid (hard) backrest will give you more protection compared to a sling/upholstered back. Also, grabbing the wheels can help slow the descent.

Power wheelchair users: If you start to fall backwards and cannot stop the movement, tuck your head, turn your face, and hold onto the arm rests. This will force the chair’s push handles or backrest to take the brunt of the fall and protect your head.

Please note: The safe fall techniques demonstrated above are difficult and require a lot of practice. If you feel that you would like to work on these techniques after the education program is over, please talk to your physician. He/she may provide a referral to a physical therapist, who will further help you with safe falling techniques.

Fall Recovery Plan

In this segment we will be discussing what to do after a fall occurs. The period of time after a fall occurs can be frightening and a period of uncertainty. Today, we will discuss different ways to help you make your own fall recovery plan and get up after a fall occurs. Developing a fall recovery plan in advance of a fall event can help to take some of the uncertainty away and increase your confidence in recovery.

Why is developing a fall recovery plan important?

• After a fall, remaining on the floor or the ground for over 10 minutes after falling is common among wheelchair users.
• Most wheelchair users need assistances to get up after a fall occurs.
• Lying on the floor or the ground for an extended period of time is associated with additional physical injuries, a decline in performance of daily activities, an increased chance of a hospital admission and increased fear of falling.

To develop a fall recovery plan, here are a few tips:

• Create a “check in” system with a close friend or family member to make sure that someone is aware of what you are doing and can summon assistance quickly if a fall occurs. Pick a friend or family member that you can trust and develop a plan to call or text him/her on a daily basis at roughly the same time each day. You do not need to make a long phone call, just check in with the person so that he/she knows that you are doing okay. If you have a history of multiple falls, you might want to develop a plan for more frequent check-ins.
• If you have a smartphone, set up the emergency features. Many modern smartphones have emergency features that can help notify family or friends if you need assistance recovering from a fall. Please see your manual for details on how to set up the emergency features for your specific phone.

Next are ways to help you stay connected.

• First, you can consider using a medical alert device. A medical alert device is a wireless device that can either be automatically or manually triggered to call for assistance when a fall occurs. The device can be worn around your neck or on your wrist to assure that it is always with you. These devices can be expensive, so make sure you shop around before selecting a device.
• Project: Please see page 75 for a listing of medical alert systems.
• Use of a wearable communication device. Many companies are developing “smart” watches or devices that allow a person to wear a device that allows them to connect to their cellular telephone. These devices can help you call for help if you get separated from your phone. These devices however can be expensive and provide more functionality than is needed to simply communicate.
• Low tech: If you would prefer not to use a medical alert system or a wearable communication device, you can develop your own low tech solution to assure you are always connected. You can put a cellular telephone in a waist (“fanny”) pack or a small pouch around your neck. When selecting a bag, make sure that it does not affect your ability to transfer, push, or drive your wheelchair/scooter, or perform any other activities of daily living.

Develop a plan to get off the floor. It is very important that you have a plan in place to be able to get up off the floor after a fall occurs. We will discuss this more in the next video segment.

Fall Recovery Strategies

This segment covers different strategies to use to get yourself off of the floor following a fall. We will discuss several options, however, depending on your specific functional abilities, you may need to modify these suggestions. Please talk with your trainer about your specific needs in the online discussion session.

When a fall occurs, please follow these steps:

• Take a deep breath and orient yourself to the situation. Don’t try to get up quickly.
• Evaluate the situation to determine if you are seriously injured. If you think you might have a broken bone or have a head injury, please call 911 or ask a bystander to call for you. As much as possible, please try to stay still to prevent further injuries.
• If you are not seriously injured, and you are able to transfer back to your wheelchair/scooter with/without assistance, please perform a floor to chair transfer (instructions to follow).
• Once you are sitting back in your seat, take a moment to make sure you are correctly positioned in your chair. Take a deep breath before going back to your normal daily activity.
• See your doctor if you are concerned about any injuries. Please see the section ‘Medical Attention After a Fall’ on page 82 of your manual to help you decide if you should call your doctor. If you hit your head, you must call your doctor.

Depending on the strength of your lower extremity, please select one of the following videos to watch next.

• If you are able to weight bear on your lower extremity and don’t need assistance to get up, please watch the video: Floor to Chair Transfers without assistance
• If you are able to bear weight of your lower extremity but do need assistance, please watch the video: Floor to Chair transfers with assistance
• If you need total assistance to perform a floor to chair transfer, you should develop a plan with your care partner ahead of time. Make sure to have your care partner practice the steps either with you or a friend/family member who can easily get on/off the floor. You should also practice providing instructions to a bystander in case a fall occurs and one of these trained individuals cannot assist you. Please watch the video: Two-Person Floor to Chair Transfer
• If you cannot bear weight on your lower extremity, please watch the 3 videos on non-weight bearing floor to chair transfers. Instructions are provided on a front, back and side approach.

Bullet points in your manual will reinforce the various materials presented in these videos.

To make the floor to chair transfer a little easier, you might want to consider the use of assistive technology. Assistive technology can play an important role in facilitating the performance of a floor to chair transfer.

Here are two devices that can make the transfer a little easier. Project picture of the para ladder and ReqQup.

These devices are essentially a series of steps that help to create intermediate surfaces between the floor and your wheelchair. To use these devices you will:

• Sit on the bottom seat.
• Push yourself up to reach the next seat.
• Have at least one caregiver assist or watch you while using the device.

Medical Attention after a Fall

After a fall occurs it is important to get the appropriate medical attention. Taking the time to speak with your doctor or a medical professional after a fall will help to prevent chronic, longstanding injuries that may have a long term, negative effect on your health and wellbeing. It is critically important that you call your doctor if you experience a fall where you:

• Hit your head
• Sustain an injury
• Have significant pain for more than 24 hours

If you have hit your head, it is particularly important that you call your doctor. In addition to calling a doctor, you should be monitored closely for signs of a concussion, even if you feel okay. An undiagnosed concussion can put you at risk for brain damage. Some important symptoms of concussion to be aware of include:

• Loss of consciousness
• Severe headache, including a headache that gets worse
• Confusion and saying things that don’t make sense
• Slurred speech
• Unresponsiveness

It is also very important to speak with your doctor if you have experienced an increase in your frequency of falls or experience a fall after a recent medication change.

Fall Management: Putting it all together

In the past several segments, you have learned a lot about fall management. This segment will put everything.

First, before a fall occurs, consider:

• If you fall, who should you contact?
  • How will you contact this person? (Medical Alert Device vs. Wearable Communication)
  • If you fall and no one is available, what would you do?
• Develop a check in plan.
• Practice floor to chair transfer skills with a few care partners.

If a fall occurs:

• Don’t panic and take a deep breath. Don’t try to get up quickly.
• Evaluate the situation to determine if a serious injury has occurred.
  • If, yes, call 911 first and then family members. Stay as still as possible to prevent making injuries worse.
  • If no, evaluate the situation and figure out what is needed to help you get back up.
• Determine if you are able to get up by yourself.
  • If, yes, perform floor to chair transfer to get back into your chair.
  • If no, ask for help using your established strategy.
• If you are waiting for assistance and not injured, attempt to get into a comfortable position and conserve energy until someone who can help you arrives. If you have limited sensation, make sure you are not putting excessive pressure on any areas.
• Once help has arrived, use your established recovery plan.
  • What are you going to say to helpers assisting you to get back up?

After getting back up to your chair:

• Re-evaluate any injuries and determine if you should call your doctor. If you hit your head, call your doctor. If you don’t feel that you are injured, monitor your
• symptoms.
• Think about if your fall recovery plan worked as you expected.
  • Do you need to modify anything?
• Think about why you fell.
  • Could the fall have been avoided?
  • Are there any skills you can work on?

Module #3 Journal and Fall Management Worksheet

You will be asked to make a journal entry every week after completion of the online module. Your journal entry will be tied to items discussed during the module.

The journal entries will help you to think about the information that was presented during the education session and to help you integrate what you have learned into your everyday life.

Please think about your worst fall in the past year. What happened after the fall occurred? Please specifically think about how you got up from the fall, how long you were on the ground and if any assistance was needed. Taking into consideration this information, what aspect(s) of your fall management plan do you think will be most important to develop or revise? Please remember to complete this journal entry before the online discussion.

This week, in addition to doing a journal entry, I would also like you to think very specifically about your fall management plan. Please turn to page 85 in your manual. You will find a worksheet to help you work through the various aspects of developing a fall management plan. We will then discuss this fall management plan during the online discussion session.

Complex Transfer Training/Toilet Transfers

In this next segment, we are going to talk about complex transfers. During the last module we discussed how to perform basic transfers.

In this segment we are going to discuss how to perform more complex transfers including transfers to toilets, vehicles, and beds. Many of the skills you learned during the previous module will be applied to these transfers.

In this segment we are going to talk about how to perform these transfers, however, because everyone has a unique environment in which these transfers are performed, we will be focusing more on general best practices. During the online discussion session, we can discuss individual situations.

Learning how to do these transfers is really important to help you do the activities you like to do. For example, if you would like to go out to dinner with a friend, you most likely will need to get in and out of a vehicle.

Please now turn to page 89 of your manual.

During the previous session you learned basic transfer skills. Please feel free to refer back to page 35 (independent)/39 (assisted) of the education material to review these skills as often as necessary. Today, we will discuss how to perform more complex transfers making use of the basic skills you learned.

We will focus today on performing transfers to and from the toilet, a vehicle, and a bed. These are some of the most common transfers you will encounter. In addition, being able to perform these transfers will help you to navigate not only your own home but increase your confidence in your ability to perform transfers necessary to participate in activities you enjoy doing.

Today, we will help you learn the fundamental skills of these transfers. However, if you would like more practice or have a particularly difficult environment in which these transfers must be performed, you might want more practice time. Please tell your doctor you are having difficulty performing these essential transfer skills and ask for him/her to order physical or occupational therapy services.

If you need assistance to transfer, please refer to the basic assisted transfer education materials on page 39 of the manual. You can use the same general techniques described in this section while performing complex transfers.

First, we will discuss toilet transfers. You can watch the video: Bathroom Transfers to see a generic toilet transfer.

Toilet transfers are often difficult due to space limitations. Because toilet transfers are performed frequently, modify your bathroom at home, if possible, to give you enough space to perform a transfer using your preferred method. The US Access Board has detailed information on ideal bathroom set ups at www.access-board.gov. If you are doing major reconstruction, it is best to work with a contractor who has experience modifying homes for wheelchair or scooter users. You should also take some time to determine if you have any unique space requirements above and beyond the standard guidelines.

Any transfer in the bathroom (i.e., toilet, shower) can become more dangerous due to wet and slippery surfaces. Please take care to make sure that your shower has a good drainage system that prevents water from pooling on the floor. If you notice water on the floor, please wipe it up as soon as possible or ask your care partner to assist you. Even a little bit of water can be very dangerous!

When you are away from your home, transfers can be more challenging because the area hasn’t been set up specifically for you. After reviewing the tips for success, your trainer can help you problem solve through unique challenges you might face.

Tips for success

• Seat height:
  • Investigate assistive technology that allows for performance of a level transfer.
  • Take measurements of your chair and compare to the toilet. Items such as elevated toilet seats or padded seats can help make the transfer level.
  • Measure before you buy! Standard toilet seats are often fairly level with wheelchairs for people performing sitting pivot transfers. However, if you perform a stand pivot transfer, an elevated seat will be very helpful.
• Grab bars:
  • Grab bars can make the transfer easier and provide a good handgrip.
  • Caution: if the grab bar is in the wrong place, it might make things worse. You should not have to lean excessively forward or to the side to grab the bar. The bar should be close to where your hand naturally falls when you transfer.
  • Use of grab bars that can be adjusted to your needs and lowered down next to the toilet allows you to modify the environment to your specific needs.

Please note: DO NOT use towel bars as a grab bar. Towel bars cannot support more than about five pounds and will break if you put your weight on them. This could result in a serious fall with substantial injuries. If you choose to use a grab bar on the wall, it should be installed by a professional contractor familiar with the process.

• Clothing management:
  • Depending on your specific toilet routine, clothing management can add an additional challenge to toilet transfers.
  • If you pull down your pants, make sure that you are on a stable surface that you can safely shift your weight.
  • If you perform the transfer after pulling down your pants, make sure that your pants are positioned so that you have freedom of movement and won’t get caught on your wheelchair or the toilet.
  • If clothing is difficult to reach from the floor following bathroom usage, you can consider a reaching aide (e.g. reacher or dressing stick) placed in close proximity to the toilet.

Please make sure to watch the video ‘bathroom transfers’ that is available after this segment. In your manual there are bullet points highlighting the key concepts in this video.

If you perform a standing pivot transfer to the toilet:

• Many of the same techniques will apply, however you may need additional space depending if you take a step during your pivot transfer.
• If you don’t have a raised toilet seat, grab bars can be very helpful.
• Make sure you either feel the toilet on the back of your legs (or see that you are in close proximity) before lowering down.

Vehicle Transfers

Welcome back. In this segment we will discuss vehicle transfers. You can watch the video: Vehicle Transfers to see a generic vehicle transfer.

Performing a transfer to/from a vehicle can be one of the most challenging transfers to perform but is very important to allow you to participate in and access your community. Because there are so many different vehicle types, the specific techniques will vary. However, we will provide general tips on methods to make the transfer safe and easy. If you would like additional, individual practice, please ask your doctor to order Occupational Therapy services for you.

Setting up your environment:

Vehicle transfers are challenging due to space limitations, a large gap between your chair and the seat and height changes. When possible, attempt to perform a level transfer into your vehicle. If you are able to buy a new vehicle, you should consider the following items:

• Modified vehicle: The safest option is to buy a vehicle with a ramp in which you can push/drive your chair into the vehicle. You can either stay in your chair (either to drive or ride as a passenger) or transfer to a seat in the vehicle. Please talk to your wheelchair vendor about resources to modify a vehicle. The National Disability Institute provides low interest loans for modified vehicles or other assistive technology. Details can be found at the following website: https://www.realeconomicimpact.org/assets/site_18/files/alternative%20financing%20programs%202-2-18.pdf

• In general, larger vehicles, that are lower to the ground make transfers easier. Transferring into a sports utility vehicle (SUV) or truck can be very challenging and put you at a high risk for falling and upper limb impairments. Station Wagons or crossover utility vehicles can give you the needed space but are also low to the ground. Mini-vans also work fairly well.

Tips for success:

• Create a solid base of support. Consider different foot placements and hand holds to create a solid foundation to perform your transfer to/from. Using the car seat or dashboard are good options. You might have to try out a few different options to figure out what is best for you.
• Consider how you will load your chair into your vehicle. Working with a therapist can help you to problem solve through a different method to load your chair independently to reduce your dependence on a care partner.

Please make sure to watch the video ‘vehicle transfers’ that is available after this segment. In your manual there are bullet points highlighting the key concepts in this video.

If you perform a stand pivot transfer:

• The same principles will apply. However, you will leave both feet outside of the car during the transfer.
• The dashboard and back of the seat are good locations to place your hands to slow your descent.

Please also note that the MS Society has a nice resource for vehicle modification needs. You can find the link for the resource in your manual.

Bed Transfer

Welcome back. In this segment we will discuss transfers to/from your bed. You can watch the video: Bed, Chair, and Couch Transfers to see a generic bed transfer.

Transferring from your bed to and from your chair is a critical skill that will be performed multiple times on a daily basis. Many of the same techniques learned during the basic transfer skills session (page 35/39) will be applied here.

Setting up your environment:

• When possible, give yourself enough space to allow you to position your wheelchair in your desired position.

• Attempt to set up your bed so that you can perform a level transfer. You may need to remove part of the bed frame or simply put your box spring and mattress directly on the floor. Platform beds can also be purchased which are often low to the ground.
• Chose a mattress that will provide sufficient support and pressure management (if necessary) but isn’t so soft that it makes the transfer difficult. You might want to go to a store and feel the mattress yourself to help make a decision.
• Consider the use of a motion activated light so that if you need to use the bathroom in the middle of the night you can easily turn on a light and won’t need to reach for a light switch.
• If you need to use the bathroom frequently, you might want to consider the use of a bedside commode that can sit next to your bed. For males, a urinal can also be a convenient option.
• Make sure that you have enough space to park your wheelchair or scooter next to your bed. Prior to performing the transfer, make sure the brakes are locked/power turned off to enhance safety during your transfer and the device is ready to go when you get out of bed.
• You may also want to consider the use of a grab bar that can be attached to the edge of your bed. One can be purchased from rehabmart.com.

Tips for success:

• Take care when getting out of bed immediately after waking. People are often disoriented and unsteady if they quickly move from a lying to a seated position. After sitting up, take a moment to orient yourself before transferring into your wheelchair.

Please make sure to watch the video ‘bed, chair, and couch transfers’ that is available after this segment. In your manual there are bullet points highlighting the key concepts in this video.

If you perform a stand pivot transfer:

• Many of the same principles will apply.
• Before sitting, make sure you can feel the bed on the back of your legs. If you have limited sensation, look to make sure that the bed is behind you.

Module #3 Goal

Welcome back. We will now be discussing the goal for the week. Please now turn to page 97 of your manual. For this week, we will be asking you to set a goal related to the complex transfer skills you just learned about. Please think about the skills you learned today and what would be most helpful to your specific circumstances. Please remember to use the SMART goal format and write your goal in the space provided. We will talk about these goals during the online discussion session.

Intermediate Wheelchair/Scooter Skills Introduction

Now we are going to talk about intermediate wheelchair/scooter skills. Last week we learned how to perform basic wheelchair/scooter skills. Today, we are going to continue to talk about wheelchair/scooter skills and learn a few new skills.

Having good wheelchair/scooter skills is important to allow you to get out into the community and do the activities that yo u enjoy doing. Today, we are hoping to increase your confidence in performing skills to help you get out and about in the community.

If you are a manual wheelchair user, please turn to page 98 of your manual and watch the video: Manual Wheelchair Skills Education (Intermediate)

If you are a power wheelchair or scooter user, please turn to page 101 of your manual and watch the video: Power Wheelchair and Scooter Skills Education (Intermediate).

Manual Wheelchair Skills Education (Intermediate)

Today, we will learn and review intermediate wheelchair skills to allow you to safely and successfully navigate a variety of environments in your home and community.

Pushing on a soft surface

We will now be watching two videos showing how to push your chair on a soft surface. These videos are also available on the study website for you to watch at a later date if you would like. The bullet points in your manual correspond to the key information presented in the video.

There are many soft surfaces (e.g. carpet, dirt, grass, gravel, or sand) that create increased rolling resistance. Pushing your wheelchair is more difficult on such surfaces because the wheels tend to sink into these surfaces.

Show the video of pushing on carpet while talking

General tips to reduce the frequency of falls and injury:

• When approaching a soft surface, look ahead and plan a route that will minimize the amount of time that you must push on this surface.
• When pushing from a smooth, level surface onto a soft surface, be aware that your wheelchair can suddenly slow down or stop because of the increased rolling resistance. It is a good idea to slow down when approaching a soft surface for a smoother transition.
• Continue to use good propulsion techniques (e.g. use long, smooth strokes—)(see page 58). You will need to use more force due to the increased rolling resistance on soft surfaces.

• Only move in a forward direction when pushing over soft surfaces so that you can see any unexpected hazards in your path.
• Keep as much weight as possible over the rear wheels without leaning backwards. This technique prevents the front casters from digging into the soft surface.
• If possible, perform a wheelie to lift the front casters off the ground. If this is not possible, consider popping up the front wheels (casters) off the surface before each push. This keeps the front wheels (casters) free from sinking or dragging into the soft surface. Lift the casters off the surface during each push, letting them touch the surface as the hands recover for the next push.

Wheelie Pop-up

We will now be watching a video showing how to lift your front wheels(casters) off the ground. This video is also available on the study website for you to watch at a later date if you would like. The bullet points in your manual correspond to the key information presented in the video.

General tips to reduce the frequency of falls and injury:

• A wheelchair pop-up involves lifting your front wheels (casters) off the ground briefly.
• Push the wheelchair forward to do a pop-up by positioning your hands on the upper back of your hand rims and applying a short, rapid short push forward to lift your front wheels (casters) off the ground. Then allow your front wheels (casters) to return to the ground.

NOTE: Make sure you have a spotter with you when learning and practicing this task. Until you are able to perform the skill correctly consistently, there is a high potential that you could fall.

Getting over an obstacle

We will now be watching a video showing how to get over an obstacle. This video is also available on the study website for you to watch at a later date if you would like. The bullet points in your manual correspond to the key information presented in the video.

You will often encounter obstacles (e.g. door thresholds) that you may not be able to simply roll over. Alternative strategies may be needed. For example, you might need to pop the casters over the obstacle

General tips to reduce the frequency of falls and injury:

• Search for an alternate route when you approach obstacles. The best method is to avoid them, steering around them or straddling them if possible.
• Approach an obstacle at a slow speed. It is easier to pop the front wheels (casters) when moving.
• Don’t lean forward when you approach the obstacle, it can increase the weight on the front wheels (casters) and make it difficult to pop the casters.
• Approach an obstacle straight forward. Approaching the obstacle to the side can make it more difficult to get over the obstacle.
• Pop the front wheels (casters) up off the floor once you are close to the obstacle you wish to overtake. Be sure to lift the front wheels (casters) just high enough to clear the obstacle.
• Use both of your hands to propel yourself forward, applying forward forces of moderate intensity to the hand-rims to pop the front wheels (casters).
• Lean forward slightly when the casters have landed beyond the obstacle and the rear wheels strike the obstacle.

Getting over a gap

We will now be watching a video showing how to get over a gap. This video is also available on the study website for you to watch at a later date if you would like. The bullet points listed in your manual correspond to the key information presented in the video.

A gap is a common barrier (e.g. potholes on the road). A gap can cause a wheel to become stuck or tip your wheelchair as you pass over, both of which can result in falling. Even if no tip or fall occurs, it can still be challenging to get your wheelchair out of a gap if a wheel becomes stuck. Therefore, it is important to learn the proper technique to avoid these situations.

General tips to reduce the frequency of falls and injury:

• Search for an alternate route when you approach gaps. The best method is to avoid them, steering around them or straddling them, if possible.
• Use the same techniques that you use when getting over an obstacle to get over a gap (See the “getting over an obstacle” skill).
• If the front wheels (casters) drop into the gap and turn sideways (a common problem if the wheelchair is moved forwards and backwards repeatedly in an attempt to get the casters out of the gap), it can be very difficult or impossible to proceed without assistance.
• Consider using the full wheelie technique to cross over a larger gap (if applicable).

Please now take some time now or later this week to practice these skills. Please remember to have a care partner with you when you are practicing these skills.

Power Wheelchair and Scooter Skills Education (Intermediate)

In this module we will discuss and review intermediate wheelchair skills to allow you to safely and successfully navigate a variety of environments in your home and community.

Driving on a soft surface

We will now be watching a video showing how to drive your chair on a soft surface. This video is also available on the study website for you to watch at a later date if you would like. The bullet points listed in your manual provide key information to help you perform the skill correctly and safely.

There are many soft surfaces (e.g. carpet, dirt, grass, gravel, or sand) with increased rolling resistance. Driving your wheelchair is more difficult on such surfaces because the wheels tend to sink into the surface.

General tips to reduce the frequency of falls and injury:

• When approaching a soft surface, look ahead and plan a route that will minimize the amount of time you must drive on a soft surface.
• When driving from a smooth level surface onto a soft surface, be aware that your wheelchair can suddenly slow down or stop because of the increased rolling resistance. It is a good idea to slow down when approaching a soft surface for a smoother transition.
• If possible, select the driving option that provides more power. Sometimes a chair has an “outdoor” mode that provides more power.
• Only move in a forward direction when driving over soft surfaces so that you can see any unexpected hazards in your path.
• On soft a soft surface, drive fast enough to maintain forward movement but not so fast that you lose control.
• Be aware that your wheelchair can get stuck on a soft surface (e.g. sand, gravel, or mud). As much as possible, avoid these surfaces. If avoidance is not possible, maintaining a moderate speed can help you from getting stuck.

Scooter considerations

• Use the same techniques as described above.
• Do your best to avoid these surfaces. Most scooters are not designed to maneuver over these surfaces.

Getting over an obstacle

We will now be watching a video showing how to get over an obstacle. This video is also available on the study website for you to watch at a later date if you would like. The bullet points in your manual provide key information to help you perform the skill correctly and safely.

You will often encounter obstacles (e.g. door thresholds) that you may not be able to simply go over.

General tips to reduce the frequency of falls and injury:

• Search for an alternate route when you approach obstacles. The best method is to avoid them, steering around them or straddling them, if possible.
• Elevate your footrests (if necessary/possible) to give you more clearance.
• Approach an obstacle at a slow speed and drive forward. Smooth, continuous, forward movement is the most successful method of traversing an obstacle.

Scooter considerations

• Use the same techniques as described above.
• Do your best to avoid these surfaces. Most scooters are not designed to maneuver over rough terrain.
• Very carefully consider the height of the obstacle before attempting to go over it. Scooters are very low the ground and often get caught on obstacles.

Getting over a gap

We will now be watching a video showing how to get over a gap. This video is also available on the study website for you to watch at a later date if you would like. The bullet points in your manual provide key information to help you perform the skill correctly and safely.

A gap is a common barrier (e.g. potholes on the road). A gap can cause a wheel to become stuck, or tip your wheelchair as you pass over, both of which can cause a fall. Even if no tip or fall occurs, it can still be challenging to get your wheelchair out of a gap if a wheel becomes stuck. Therefore, it is important to learn the proper technique to avoid these situations.

General tips to reduce the frequency of falls and injury:

• Search for an alternate route when you approach gaps. The best method is to avoid them, steering around them or straddling them, if possible.
• If avoidance is not possible, use the same techniques as described in the “getting over an obstacle” section. Maintaining a controlled, forward motion will give you the necessary momentum to transverse the obstacle.
• If the small wheels (casters) get stuck sideways in the gap (a common problem), move your wheelchair forwards and backwards repeatedly to get the casters out of the gap.
• Ask for assistance to get out of the gap if the wheelchair gets stuck and you cannot manage it.

Scooter considerations

• Use the same techniques as described above.
• When possible, avoid going over a gap in your scooter. Due to the low clearance and instability of a scooter, you are at high risk of falling.

Please now take some time now or later this week to practice these skills. Please remember to have a care partner with you when you are practicing these skills.

Closing Remarks

We are now going to wrap up the material for this module. Before we go, I would like to remind you of a few things to do prior to the online discussion:

• Continue doing the home exercise program 3x/week. (page 16).
• Use your exercise log to track your exercises. (folder).
• Work toward completion of fall management plan (page 85).
• Goal form: Practice either a toilet, vehicle, or bed transfer (page 97).
• Complete your journal entry (page 84).

In the next module we will be covering the following items:

G – Goals toward engagement in desired activities will be set.
E – Discussion on how exercise can be used to manage MS related symptoms.
T – Check in on the performance of complex transfer skills (toilet, vehicle, and bed).

W – Final session of new wheelchair/scooter skills in challenging environments (curbs, ramps, and wheelie)
I – Discussion on engagement in desired activities will be held.
S – The influence of MS Symptoms on falls will be discussed.
E – Discussion on the influence of the environment on engagement in desired activities will be held.